Provider Demographics
NPI:1336862325
Name:CHILINDRISHVILI, TEONA (PA)
Entity type:Individual
Prefix:
First Name:TEONA
Middle Name:
Last Name:CHILINDRISHVILI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W I ST APT 22
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-3519
Mailing Address - Country:US
Mailing Address - Phone:314-366-2333
Mailing Address - Fax:
Practice Address - Street 1:1045 5TH ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4204
Practice Address - Country:US
Practice Address - Phone:209-827-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0007481363A00000X
CA61733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant